OA Guide to Heat Related Illnesses
& Fluid Balance

by Rick Curtis

Heat injuries can be immediately life-threatening. Be aware of the
temperature conditions and your hydration levels. The information provided
here is designed for educational use only and is not a substitute for specific
training or experience. Princeton University and the author assume no liability
for any individual's use of or reliance upon any material contained or
referenced herein. This article is prepared to provide basic information
about heat related illnesses for the lay person. Medical research is always
expanding our knowledge of the causes and treatment. It is your responsibility
to learn the latest information. The material contained in this article
may not be the most current. Copyright &COPY; 1997 Rick Curtis,
Outdoor Action Program, Princeton University.

Fluid Balance

All the body's fluids make up one large body fluid pool. Losses of fluid
from any one source is reflected in the levels of all the body's other fluids:
e.g. profuse sweating will ultimately result in decreased blood volume.
If a patient loses enough fluid through any manner-bleeding, sweating, vomiting,
or diarrhea-the end result is the same: dehydration and, potentially, volume
shock. Adequate fluid is also critically important in hot environments to
help our body thermoregulate (see Heat Illnesses page 00). Remember, dehydration
can kill!

If someone is chronically losing fluid (from diarrhea or vomiting), then
you have a real emergency on your hands. Treat the cause of the fluid lose
as best you can (see Shock page 00, Bleeding page 00, Heat Illnesses page
00, Abdominal Infections page 00) and rehydrate the patient. Be prepared
to evacuate your patient.

Dehydration is always easier to prevent than it is to treat. So it is
important to ensure that all members of your group replace their regular
fluid losses by drinking adequate amounts of water (see below). Your body
absorbs fluids best when you drink frequently and in small amounts rather
than drinking large amounts at one time. It also helps with fluid absorption
if you drink while eating. A pinch of salt and sugar in the water will do
if no food is available. Very dilute mixtures of sports drinks like Gatorade&REG;
(add just enough to taste) work well for this purpose.

Don't depend on feeling thirsty to tell you when to drink. Thirst is
a late response of the body to fluid depletion. Once you feel thirsty, you
are already low on fluids. The best indicator of proper fluid levels is
urine output and color. You, and all the people in your group should strive
to be "copious and clear." Ample urine that is light colored to
clear shows that the body has plenty of fluid. Dark urine means that the
body is low on water, and is trying to conserve its supply by hoarding fluid
which means that urine becomes more concentrated (thereby darker).

Basic Fluid Recommendations

Season/Weather

Quarts/day

Explanation

Fall & Spring Backpacking*

2-3 quarts
1.8-2.8 liters

This is what an average person will need on a daily basis in general temperate
conditions.

Hot Weather Backpacking*

3-4 quarts
2.8-3.7 liters

In hot and humid weather you are losing additional fluid through sweating
which must be replaced.

Winter Backpacking*

3-4 quarts
2.8-3.7 liters

In the winter time you are losing moisture through evaporation to the dry
air and especially through respiration. Dry air entering the lungs heats
up and is exhaled saturated with moisture.

*All Seasons

Add 1quart
1.8 liters

At high altitude the body looses more fluid. Increase your fluid intake
if you are traveling at high altitudes (over 8,000 feet/2,438 meters)

Table 9.1

Fluids & Salts:

Another factor in overall fluid balance is the replacement of salts lost
to sweat. In most cases the salts found in normal food consumption is adequate
for salt replacement. In the event of severe dehydration, a solution of
½ teaspoon salt and ½ teaspoon of baking soda per quart/liter
of water can be used to replace lost fluid and salt. Use lukewarm fluids.
Discontinue the fluids if the person becomes nauseated or vomits. Restart
fluids as soon as the person can tolerate it.

Thermoregulation

The body has a number of mechanisms to properly maintain its optimal
core temperature of 98.6° F (37° C). Above 105° F (40° C)
many body enzymes become denatured and chemical reactions cannot take place
leading to death. Below 98.6° F (37° C) chemical reactions slow
down with various complications which can lead to death. Understanding thermoregulation
is important to understanding Heat Illnesses and Cold Injuries.

Shivering - generates heat through increase in chemical reactions
required for muscle activity. Visible shivering can maximally increase
surface heat production by 500%. However, this is limited to a few hours
because of depletion of muscle glucose and the onset of fatigue.

Increasing/Decreasing Activity will cause corresponding increases
in heat production and decreases in heat production.

Behavioral Responses - putting on or taking off layers of clothing
will result in thermoregulation

Cold Challenge

Whenever you go into an environment that is less than your body temperature,
you are exposed to a Cold Challenge. As long as your levels of Heat Production
and Heat Retention are greater than the Cold Challenge, then you will be
thermoregulating properly. If the Cold Challenge is greater than your combined
Heat Production and Heat Retention, then you susceptible to a cold illness
such as hypothermia or frostbite (see Table 9.3).

Heat Retention - (positive factors)

Shell/Core Response - allows the body shell to act as a thermal barrier

Heat Production - (positive factors)

Exercise

Shivering

Heat Retention

+

Heat Production

<

Cold Challenge

=

Cold Injury

Body Size/shape
Insulation
Body Fat
Body shunting blood to the core

Exercise
Shivering

Temperature Wetness
Wind

Hypothermia
Frostbite

Table 9.2

Wind Chill

Wind Chill can have a major impact on heat loss through convection (see
Chapter 2 - Equipment: Regulating Your Body Temperature). As air heated
by your body is replaced with cooler air pushed by the wind, the amount
of heat you can lose in a given period of time increases. This increase
is comparable to the amount of heat you would lose at a colder temperature
with no wind. The Wind Chill factor is a scale that shows the equivalent
temperature given a particular wind speed.

Heat Challenge

In hot weather, especially with and humidity, you can lose a great deal
of body fluid through exercise. This can lead to a variety of heat related
illnesses including Heat Exhaustion and Heat Stroke. Heat Challenge is a
combination of a number of external heat factors. Balanced against this
Heat Challenge is your body's methods of Heat Loss (passive and active).
When Heat Challenge is greater than Heat Loss, you are at risk for a heat-related
injury (see Table 9.4). In order to reduce the risk you need to either decrease
the Heat Challenge or increase your Heat Loss. Fluids are a central part
of exercising in a Heat Challenge (see Fluids above).

Passive Heat Loss - (positive factors)

Shell/Core Response - allows the body shell to act as a thermal barrier

Active Heat Loss - (positive factors)

Radiant Heat from the body.

Sweating which causes heat loss through evaporation. Amount of sweating
is limited by:

Fluid Levels

Level of Fitness

Passive Heat Loss

+

Active Heat Loss

<

Heat Challenge

=

Heat Injury

Body Size/shape
Insulation
Body Fat
Body shunting blood to the core

Radiant Heat
Sweating

Temperature Exercise
Humidity
Body Wetness
Wind

Heat Syncope
Heat Exhaustion
Heat Stroke

Table 9.4

The Heat Index:

Ambient temperature is not the only factor that plays a role in creating
the potential for heat injuries, humidity is also important. Since our bodies
rely on the evaporation of sweat as a major method of cooling, high humidity
reduces our ability to cool the body, increasing the risk of heat illnesses.
The Heat Index shows the relative effects of temperature and humidity (see
Table 9.5).

The Heat Index

Environmental Temperature Fº
(Cº)

70º (21)

75º(24)

80º(27)

85º(29)

90º(32)

95º(35)

100º(38)

105º(41)

110º(43)

115º(46)

120º(49)

Relative Humidity

Apparent Temperature Fº (Cº)

0%

64º(18)

69º(20)

73º(23)

78º(26)

83º(28)

87º(31)

91º(33)

95º(35)

99º(37)

103º(39)

107º(42)

10%

65º(18)

70º(21)

75º(24)

80º(27)

85º(29)

90º(33)

95º(35)

100º(38)

105º(41)

111º(44)

116º(47)

20%

66º(19)

72º(22)

77º(25)

82º(28)

87º(30)

93º(33)

99º(37)

105º(41)

112º(44)

120º(49)

130º(54)

30%

67º(19)

73º(23)

78º(26)

84º(29)

90º(33)

96º(36)

104º(40)

113º(45)

123º(51)

135º(57)

148º(64)

40%

68º(20)

74º(23)

79º(26)

86º(30)

93º(34)

101º(38)

110º(43)

123º(56)

137º(58)

151º(66)

50%

69º(20)

75º(24)

81º(27)

88º(31)

96º(36)

107º(42)

120º(49)

135º(57)

150º(66)

60%

70º(21)

76º(24)

82º(28)

90º(33)

100º(38)

114º(46)

132º(56)

149º(65)

70%

70º(21)

77º(25)

85º(29)

93º(34)

106º(41)

124º(51)

144º(62)

80%

71º(22)

78º(26)

86º(30)

97º(36)

113º(45)

136º(58)

90%

71º(22)

79º(26)

88º(31)

102º(39)

122º(50)

100%

72º(22)

80º(27)

91º(33)

108º(42)

Apparent Temperature

Heat-stress risk with physical activity and/or
prolonged exposure.

90º-104º (32-40)

Heat cramps or Heat Exhaustion possible

105º-130º (31-54)

Heat cramps or Heat Exhaustion likely.
Heat Stroke possible.

130º and up (54 and up)

Heat Stroke very likely.

Caution:
This chart provides guidelines for assessing the potential severity of heat
stress. Individual reactions to heat will vary. Heat illnesses can occur
at lower temperature than indicated on this chart. Exposure to full sunshine
can increase values up to 15º F.

Table 9.5

Heat Illnesses

Heat illnesses are the result of elevated body temperatures due to an
inability to dissipate the body's heat and/or a decreased fluid level. Always
remember that mild heat illnesses have the potential of becoming severe
life threatening emergencies if not treated properly (See Fluid Balance
above).

Heat Cramps

Heat cramps are a form of muscle cramp brought on by exertion and insufficient
salt.

Heat Syncope

Heat Syncope (fainting) is a mild form of heat illness which results
from physical exertion in a hot environment. In an effort to increase heat
loss, the skin blood vessels dilate to such an extent that blood flow to
the brain is reduced, resulting in symptoms of faintness, dizziness, headache,
increased pulse rate, restlessness, nausea, vomiting, and possibly even
a brief loss of consciousness. Inadequate fluid replacement which leads
to dehydration contributes significantly to this problem.

Heat Syncope Treatment

Heat Syncope should be treated as fainting (See Fainting). The person
should lie or sit down, preferably in the shade or in a cool environment.
Elevate the feet and give fluids, particularly those containing salt (commercial
"rehydration" mix or ½ teaspoon salt and ½ teaspoon
baking soda per quart/0.9 liter) (see Fluid Balance page 00). The patient
should not engage in vigorous activity for at least the rest of that day.
Only after s/he has completely restored his/her body fluids and salt and
has a normal urinary output should exercise in a hot environment be resumed
(and then cautiously).

Heat Exhaustion

This occurs when fluid losses from sweating and respiration are greater
than internal fluid reserves (volume depletion). Heat Exhaustion is really
a form of volume shock. The lack of fluid causes the body to constrict blood
vessels especially in the periphery (arms and legs). To understand Heat
Exhaustion think of a car with a radiator leak pulling a trailer up a mountain
pass. There is not enough fluid in the system to cool off the engine so
the car overheats. Adding fluid solves the problem. The signs and symptoms
of Heat Exhaustion are:

Sweating

Skin - Pale, clammy (from peripheral vasoconstriction)

Pulse - Increased

Respirations - Increased

Temperature - normal or slightly elevated

Urine Output - Decreased

Patient feels weak, dizzy, thirsty, "sick," anxious

Nausea and vomiting (from decreased circulation in the stomach)

Heat Exhaustion Treatment

Victims of Heat Exhaustion must be properly re-hydrated and must be very
careful about resuming physical activity (it is best to see a physician
before doing so). Treatment is as described above for Heat Syncope, but
the person should be more conservative about resuming physical activity
to give the body a chance to recover. Have the person rest (lying down)
in the shade. Replace fluid with a water/salt solution (commercial "rehydration"
mix or ½ teaspoon salt and ½ teaspoon baking soda per quart/0.9
liter) (see Fluid Balance page 00). Drink slowly, drinking too much, too
fast very often causes nausea and vomiting.

Evacuation usually is not necessary.Heat Exhaustion can become
Heat Stroke if not properly treated (see Heat Stroke below). A victim
of Heat Exhaustion should have be closely monitored to make sure that their
temperature does not go above 103° F (39° C) If it does so, treat
the person for Heat Stroke as described below.

Heat Stroke - Hyperthermia

Heat Stroke is one of the few life threatening medical emergencies.
A victim can die within minutes if not properly treated. Heat
Stroke is caused by an increase in the body's core temperature. Core temperatures
over 105° (41° C) can lead to death. The rate of onset of Heat Stroke
depends on the individual's fluid status. To understand Heat Stroke think
of that same car pulling a trailer up a mountain pass on a hot day. This
time the radiator has plenty of fluid, but the heat challenge of the engine
combined with the external temperature is too much. The engine can't great
rid of the heat fast enough and the engine overheats. There are two types
of Heat Stroke-fluid depleted (slow onset) and fluid intact (fast onset).

Fluid depleted - The person has Heat Exhaustion due to
fluid loss from sweating and/or inadequate fluid replacement, but continues
to function in a heat challenge situation. Ultimately, the lack of fluid
has minimized the body's active heat loss capabilities to such an extent
that the internal core temperature begins to rise. Example: a cyclist on
a hot day with limited water.

Fluid intact (fast onset) - The person is under an extreme
heat challenge. The heat challenge overwhelms the body's active heat loss
mechanisms even though the fluid level is sufficient. Example: a cyclist
pushing hard on a 104° F day (40° C).

Signs & Symptoms of Heat Stroke

The key to identifying Heat Stroke ishot skin. Some
victims may have hot, dry skin, others may have hot, wet skin because they
have just moved from Heat Exhaustion to Heat Stroke.

Peripheral vasoconstriction (skin gets pale)

Pulse Rate - increased

Respiratory Rate - increased

Urine Output - decreased

Temperature - increased (may be over 105° F/41° C)

Skin - may be wet or dry, flushed

AVPU - Severe changes in mental status and motor/sensory changes, then
the person may become comatose, possibility of seizures.

Pupils - may be dilated and unresponsive to light

Heat Stroke Treatment

Efforts to reduce body temperature must begin immediately! Move
the patient (gently) to a cooler spot or shade the victim. Remove clothing.
Pour water on the extremities and fan the person to increase air circulation
and evaporation. Or cover the extremities with cool wet cloths and fan
the patient. Immersion in cool (not cold)water is also useful.
During cooling the extremities should be massaged vigorously to help propel
the cooled blood back into the core.

After the temperature has been reduce to 102° F (39° C), active
cooling should be reduced to avoid hypothermia (shivering produces more
heat). The patient must be monitored closely to make sure that temperature
does not begin to go up again.

Volume replacement - the victim will probably need fluid regardless
of the type of onset.

Basic life support, CPR if needed.

Afterwards there can be serious medical problems. Prepare to evacuate
your patient.

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